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DEPARTMENT OF THE NAVY BUREAU OF MEDICINE AND SW1GERY

2300 E STREET NW

WASHINGTON DC 20372·5300

BUMED INSTRUCTION 6600.19

From: Chief, Bureau of Medicine and Surgery

IN AEPl V REFER TO

BUMEDINST 6600.19 BUMED M3/5 3 Sep 2010

Subj: NAVMED 6600/13, DENTAL EXAMINATION FORM; NAVMED 6600114, DENTAL TREATMENT FORM; AND NAVMED 6600115, CURRENT STATUS FORM

Ref: (a) DoD Instruction 6025.19 ofJanuary 3, 2006 (b) BUMEDINST 66OO.16A (c) SECNAVINST 6120.3

Encl: (I) Instructions for Completing the Forms to Document a Dental Examination (2) Sample Markings for use on NA VMED 6600115, Current Status

I. Purpose. To issue guidance for use of NAVMED 6600113, Dental Examination; NA VMED 6600114, Dental Treatment; and NAVMED 6600/15, Current Status.

2. Scope. This instruction applies to dental health care providers in all Naval Medical and Dental Treatment Facilities (MTFs and DTFs) ashore and afloat.

3. Background. Per reference (a), Service members require an annual dental examination to determine dental classification status, which is a factor in assessing world wide deployability. Documentation of the dental examination is currently completed on BUMED EZ 603 .2 (trial) of 2003, which has been modified with various overlays at different MTF sites to reflect advances in patient care, effectively resulting in non-standardized dental examination documentation. It is important that documentation of examination findings remains consistent throughout Navy Medicine since the documentation of examination findings and treatment needs is a vital element of the medical-legal record of dental care.

4. Policy and Procedures. All providers performing dental exanlinations in Naval MTFs and DTFs, except when completing mass examinations on new accessions at Navy and Marine Corps Recruit Centers using the Smart Card Dental Information system, must use NA VMED 6600113 to document dental examination findings beginning with the first annual dental examination following release of this instruction. Treatment documentation contained on previous versions of the Current Status form will not be transcribed onto NA VMED 6600115. Use NA VMED 6600114 beginning with the first dental treatment visit following release of this instruction. Enclosure (1) contains instructions for completing these forms. Enclosure (2) illustrates markings used on NA VMED 6600115.

5. Fomls. The following are specialty forms and are not authorized for local reproduction. They can be ordered using the listed stock number (SN) from Naval Forms Online at: https:llnavalforms.daps.dla.millweb/public/home.

BUMEDINST 6600.19 3 Sep 2010

a. NA VMED 6600/13 (01-2010), Dental Examination, SN 0105-LF-128-1500.

b. NAVMED 6600/ 14 (01-2010), Dental Treatment, SN 0105-LF-128-2700.

c. NAVMED 6600/15 (01-2010), Current Status, SN 0105-LF-128-3900.

;4. 'n-J. ~~~. A. M. ROBINSON, JR.

Distribution is electronic only via the Navy Medicine Web Site at: http://www.med.navy.mil/directives/Pages/defuult.aspx

2

BUMEDINST 6600. 19 3 Sep 2010

INSTRUCTIONS FOR COMPLETING THE FORMS TO DOCUMENT A DENTAL EXAMINATION

I . General Comments

a. NA VMED 6600/13, Dental Examination replaces the current EZ 603.2 (trial) and all previous dental examination forms. Use for the periodic or annual recall dental examinations subsequent to initial accession. For purposes of medico-legal documentation, all entries on this form will be made in black ink except as noted.

b. The front of NA VMED 6600/\3 follows the Subjective, Objective, Assessment, and Plan (SOAP) note format of the examination. The form is designed so that the examiner can comment on all areas required in a thorough exam. Negative findings will be documented where prompted. Expanded comments are to be entered on the back ofNAYMED 6600/13. Emergency, specialty consult exams, and ongoing treatment which occur prior to the next annual exam will be documented on NAVMED 6600114, Dental Treatment, accompanied by the appropriate update of the "Plan" section on the front ofNA VMED 6600/13 and NAVMED 6600/\5, Current Status, as applicable.

c. The Plan section of NAVMED 6600/13 has been designed so that the following information can be seen at a glance without sifting through numerous pages:

(I) Progress to date on completion of treatment plan.

(2) Next item on treatment plan to be completed.

(3) Portion of treatment plan not completed.

(4) Dental classification.

(5) Last dental examination date.

(6) Treatment needs for easy data entry into the CUlTent reporting data base.

2. Instructions for Completing the Front of NAVMED 6600/13

a. "S" (Subjective)

(I) Chief Complaint: Record any complaint in the patient's words. (The diagnosis is not made here but rather in the "A" section.)

(2) Age and Gender: self-explanatory.

(3) Pain Level: If the patient reports pain, determine the pain level on a scale of 0-10.

Enclosure (1)

BUMEDlNST 6600.19 3 Sep 2010

Note: Use reverse side of NA VMED 6600113 to describe pain and document a plan to address the pain, as needed.

(4) Current Tobacco Use: self-explanatory. If "yes," document type, quantity, frequency, and duration on reverse side of NAVMED 6600/13.

b. "0" (Objective). This area of the form is used to record findings. The only exception is the caries section where the finding and diagnosis are considered the same.

(I) Health Questionnaire Review (HQR) Findings: Circle within normal limits (WNL) or see dental health questionnaire (DHQ) as applicable. Reference DHQ to indicate medical findings which might affect dental treatment. Ensure these findings are properly documented on the DHQ.

(2) Medications Reviewed: Reviewing with the patient his or her current medications is an important process to help ensure patient safety during the treatment planning and execution phases. This block has been placed to remind providers to review any current medication information with the patient, and to proceed with any special medication management and safety process if required by command policy and current accreditation requirements.

(3) Blood Pressure: Record.

(4) Radiographs Ordered: Check appropriate box(es) and write the tooth number(s) of the periapical radiograph(s) ordered. If no new radiographs have been ordered. it is permissible to write the dates of any previous radiographs that have been reviewed to support the current examination, followed by the abbreviation "rev" to indicate review.

(5) Radiographic Findings: Document any findings, including results from current radiographs and/or serial exams.

(a) NA VMED 6600/13: Record an radiographic findings (except caries) in descriptive terms, mentioning size, location, and appearance.

(b) NAVMED 6600115: In box I, draw the findings in pencil. Radiolucent periradicular lesions are drawn with an outline; radiopaque periradicular lesions are drawn as a solid.

(6) Caries, Defective Restorations, and Fractured Teeth

(a) NA YMED 6600/13: Circle "None" or complete by writing in the tooth number and surfaces affected, (Example: #3 - mesio-occlusal-distal (MOD) restoration).

2 Enclosure (I)


(b) NAYMED 6600/15: In box I , draw in pencil the anticipated appearance orthe planned restoration . This is technically part of the "Plan" portion of the SOAP note, but is logically done at this time.

1- Amalgam restorations: Outline and block in.

I. Gold restorations: Outline and inscribe with diagonal lines within the outline.

1. Non-metallic restorations: Outline only. Do not block in or inscribe with diagonal lines.

1. Combination restorations: Outline the anticipated appearance, showing overall size, location, and shape. Indicate each portion according to type of material as outlined above.

(7) Incipient Lesions

(a) NAYMED 6600/13: For incipient caries write the tooth number and surfaces affected (Example: #5 - mesio-occlusal (MO) restoration).

(b) NAYMED 6600/15: Incipient caries are NOT to be identified on the NA YMED 6600/15.

(8) Oral Cancer Screen (OCS)lSoft Tissue: Document any positive findings here and on reverse side of the NAYMED 6600/13 if more space is needed. For negative findings , circle "WNL."

(9) Periodontal (Perio): Document any relevant findings. For negative findings, circle "WNL."

(10) PSR (Periodontal Screen and Recording) Score: Place the appropriate number in each of the 6 boxes of the grid. Use "Perio Findings" to explain any asterisks recorded.

(II) Endodontics (Endo): Document any relevant findings. For negative findings, circle "WNL."

(12) Temporomandibular Joint (TMJ): Document any relevant findings. For negative findings, eircle "WNL."

(13) Occlusion: Document any relevant findings. For negative findings, circle "WNL."

3 Enclosure (1 )


(14) Oral Surgery: Annotate as needed. Third molar communications with the oral cavity will be noted as pru1ial eruptions. For negative findings, circle "WNL."

(IS) Other findings: Use this section to explain other fmdings that do not fall into other listed categories. If none, circle "none."

c. "A" (Assessment). This section is generally used to make a diagnosis.

(I) Assessment of Chief Complaint: A diagnosis (differential or definitive) must be made and documented in this area if a chief complaint was recorded.

(2) Perio: Circle the appropriate condition.

(3) Endo:

(a) NA YMED 6600/13: Indicate tooth number and diagnosis.

(b) NA YMED 66001 IS: In box I, indicate in pencil the indicated root canal treatment. As with the caries in the "0" section, this action is technically part of the plan, but is logically done at this point.

1. Root canal: Draw a line down the root or roots of teeth involved tracing the location of the root canal. If a periradicular lesion is present, outline approximate size, form, and loeation.

l. Apicoectomy: Draw a small triangle on the root of the tooth involved, apex away from the crown, the base line to show the approximate level of root amputation.

(4) Oral Surgery:

(a) NAYMED 6600/13: Indicate tooth number and diagnosis.

(b) NAYMED 6600/15, box I.

1. Teeth recommended for extraction: Draw two parallel pencil lines through the tooth . Procedures treatment planned to restore function are drawn after teeth are removed.

l. Fractured tooth root: Indicate with a zigzag line on outline of tooth root.

1. Radiolucent lesions: Draw an outline of the approximate form and size in relative position on the dental chart. Do not block in.

4 Enclosure (I)

B UMEDlNST 6600.19 3 Sep 2010

(5) Other: Use this section for things that do not fall into other listed categories.

(6) Risk Assessment Block: Categorize the patient's risk for developing caries, periodontal disease, and cancer.

d. "P" (Treatment Plan). This section is comprised of the type of treatment, treatment needs (with urgent and routine sub-columns), and "Data Entry" columns.

(I) SEQUENCE (Seq). This column assigns the "ideal" sequence, by type of treatment, over which the treatment is to occur. A number is placed in the column next to the appropriate type of treatment accordingly. Qrdinarily, "Urgent" treatment will have a higher priority than "Routine" treatment.

(2) DEPARTMENTITREATMENT NEEDS

(a) Oral Hygiene

1- If Oral ProphylaxislScalingIRoot Planing is to be part of the treatment plan, place the treatment plan sequence number in the appropriate Sequence Colunm of the corresponding phase (Urgent or Routine) column. For instance, if the root planning is Urgent and comes first in the plan, write a" I" in the Sequence block of the Urgent column.

1. Circle the desired provider level in either the Urgent or Routine sub column.

1- If a subsequent provider wishes to amend the treatment plan, line through the currently circled treatment and circle the desired treatment. The sequence number may also be changed by lin ing through the current number and writing in a new number. Document any changes to the initial treatment plan on NAVMED 6600114.

1. In the Data Entry column, circle" I " for registered dental hygienist (RDH), "2" for prophy tech, or "3" for dental officer (DO) in the appropriate phase (Urgent or Routine) section. Leave blank if no treatment is indicated. Use pencil for the data entry.

,2. Update both the Treatment Needs and Data Entry columns after each treatment session by doing one of the following:

g. If another treatment session is desired by the same type provider, do not amend the notation in the Treatment Needs and Data Entry columns.

Q. If another treatment session is desired with a different type provider, line through the currently circled provider and circ le the desired provider number in the Treatment Needs column. To change the data entry, erase the current pencil mark and circle the desired entry with pencil.

5 Enclosure ( I )


£. If treatment is complete, line through the currently circled numbers in the Sequence and Treatment Needs column and erase the pencil mark in the Data Entry column.

(b) Sealants

1. NAVMED 6600/13: Write the teeth numbers (or letters) needing treatment. Complete remainder of section in the same way as the operative section.

2,. NAVMED 6600/15: In box 1, write the letter "S" on the occlusal surface of tooth to be sealed.

(c) Operative

1. Place the treatment plan sequence number in the appropriate Sequence Block of the corresponding phase (Urgent or Routine) sub column.

l,. Write the number(s) or letter(s) of teeth needing restoration in the appropriate Phase (Urgent or Routine) section of the Treatment Needs column. Leave blank if no treatment is indicated.

J Class 3 (Urgent) operative treatment needs are designated as either REGULAR or (*) HIGH PRIORITY. "High" Priority conditions include but are not limited to symptomatic operative treatment needs and caries lesions extending 1/3 of the way or greater into dentin. Teeth should be designated "High" priority when the examination findings leave questions about whether they belong in a "regular" or "high" priority category.

1. If a specialty evaluation is required, write what needs to be evaluated next to the tooth number needing evaluation in the Treatment Needs column. (Ex: Eval #3 for restorability.)

,1. In the Data Entry column, circle the total number (not individual tooth numbers) of teeth needing treatment in each phase in pencil (Urgent or Routine). (Include in this number those teeth requiring evaluation.)

Q. Subsequent examiners and providers can change the operative treatment plan by lining through the numbers written in the Treatment Needs column and writing in the tooth numbers or letters of the revised plan. Likewise, the Data Entry column must be changed by erasing the currently circled number and circling in pencil the revised number of teeth to be treated. The amender must fully document the changes to the treatment plan on NAVMED 6600114. The amender must also update the pencil entries on NAVMED 6600115.

1. Afler each treatment visit, update the Treatment Needs column by lining through the numbers or letters of teeth restored. Also update the Data Entry COlUllUl by erasing the currently circled number and circling in pencil the remaining number of teeth (not individual

6 Enclosure (I )


tooth numbers) needing restoration in each phase (Urgent or Routine). When treatment is complete, all numbers and letters in the Treatment Needs and Sequence columns will be lined through and in Data Entry column, all circled numbers will have been erased. Also after each treatment visit, update the pencil and ink entries on NA VMED 6600/15.

(d) Periodontics

1. The periodontal section has been revised to more accurately reflect the type of treatment needed. At the time of examination, the provider will place the treatment plan sequence number in the appropriate Sequence column of the corresponding phase (Urgent or Routine) column. In the Consultation section of the Treatment Needs column, note if the patient needs either an urgent or routine periodontal evaluation and circle in penci I the "I" in the corresponding "Eval" Data Entry column. Write in a specific tooth, lesion or area needing evaluation. (Example: Evaluation #27 area for mucogingival defect). Line through the Sequencing column number when the evaluation is complete.

I. The non-surgical and surgical categories in the Treatment Needs column are to be completed by the provider providing the periodontal therapy. The periodontal provider will circle which quadrants require non-surgical urgent or routine therapy as appropriate in the "Nonsurgical" section of the Treatment Needs column. In a similar manner, the periodontal provider will annotate surgical needs in the surgical section. Changes are made as previously discussed. Line through quadrant numbers when treatment is complete.

;i. In the non-surgical category Data Entry column circle in pencil the total number of quadrants requiring Urgent or Routine nonsurgical therapy as appropriate. In a similar manner complete the surgical category Data Entry column. When treatment is complete, all numbers in the Sequence and Treatment Needs will be lined through, and circles in Data Entry columns will have been erased.

( e) Oral Surgery

1- Place the treatment plan sequence number in the appropriate Sequence Block of the corresponding phase (Urgent or Routine) column. Line through the number when treatment is complete.

I. In the appropriate phase (Urgent or Routine) of the Treatment Need column, circle the 3rd molars to be extracted. Write in other teeth numbers or letters to be extracted and other treatment such as biopsy. If an evaluation is desired, write it down in the Consultation row of the appropriate Treatment Needs column (Example: Evaluate impacted # II for extraction). Changes are made as in previous sections. Line through teeth numbers when treatment for those teeth is complete. After each treatment session, update the pencil and ink entries on NA YMED 6600/15.

7 Enclosure (1)


J The complexity envisioned in the extraction of teeth will guide whether the oral surgery treatment is planne.d as "simple" or "complex" (includes impacted tooth removal). See the Dental Procedure Codes detlnitions for detailed guidance.

1. In the Data Entry column, circle in pencil the total number of teeth (not individual teeth identification numbers) needing extraction in each phase (Urgent or Routine). After each treatment session, update this column by erasing the currently circled number and circling in pencil the number of teeth remaining to be extracted. Update the pencil and ink entries on NAVMED 6600/15. When all treatment is complete, all numbers in the Sequence, Treatment Needs will be lined through and all circles on the Data Entry column will have been erased.

(f) Endodontics

1. Place the treatment plan sequence number in the appropriate Sequence Block of the corresponding phase (Urgent or Routine) sub column. Line through the number when treatment is complete.

l. Write in the individual tooth identification numbers of teeth needing endodontic treatment, in either the Anterior or Posterior section of the Treatment Need column. Amend if necessary as described in previous paragraphs.

J If an evaluation is required, write in the specific problem in the Consultation row of the Treatment Needs, Urgent sub column. (Example: Evaluate vitality #14).

1. In the Data Entry column, circle in pencil the total number of teeth (not individual teeth identification numbers) needing treatment in either Urgent or Routine, including teeth needing an evaluation. Update Treatment Needs and Data Entry columns after each treatment session as above. Update NAVMED 6600115 when treatment for each tooth is complete.

(g) Prosthodontics

1. Place the treatment plan sequence number in the appropriate Sequence Column of the corresponding phase (Urgent or Routine) sub column. Line through the number when treatment is complete.

2. In the appropriate Treatment Needs sub column, write in the individual teeth.

J If an evaluation is needed, write the specifics in the Consultation row of Treatment Needs column. (Example: evaluate margins, crown # 8 - redo?).

8 Enclosure (1)


1. [n the appropriate phase (Urgent or Routine) of the Data Entry column, circle in pencil the total number of units of fixed required. For removable, circle the number of appliances needed. Update treatment needs and Data Entry sections after each treatment session as above. Update NAVMED 6600/15 using the following markings:

ll. Non-metallic crowns, facings and pontics: Outline each a~pect of the crown.

Q. Gold and other cast metallic crowns and pontics: Outline and inscribe diagonal lines within the outline .

.:;.. Fixed partial dentures: Draw a horizontal line connecting the retainer(s) and pontic(s).

fl.. Removable appliances: Place a line over numbers of the teeth to be replaced (Box I) or teeth replaced (Box 2).

~. Porcelain crown with post: Outline each aspect of the crown; outline and block in approximate size and position of the post or posts.

(h) Other

1. Place the treatment plan sequence number in the appropriate Sequence Block of the corresponding phase (Urgent or Routine) column. Place a line through the number when treatment is complete.

~. In the Treatment Needs column, write in narrative form the action desired. Examples of treatment classified as "Other" for these purposes include Oral Diagnosis/Medicine, Orofacial Pain and Orthodontics.

J If changes are made, line through original treatment and write in the change. documenting on NAVMED 6600114.

1. In the Data Entry column, circle in pencil the number " I" in the appropriate Phase (Urgent or Routine) sub column.

,1. When treatment is complete, all entries in the Treatment Needs column are lined through, and the circle in the Data Entry column will have been erased.

(i) Caries Risk Management: Based on the Risk Assessment in the " A" section of this form, document if a high or moderate caries risk protocol is indicated by checking the appropriate box and then write the individualized caries risk plan that will meet this patient's needs. Refer to reference (b) for details on the most currentlbest accepted caries ri sk treatment modalities as required.

9 Enclosure (I)


(j) Additional Remarks: All documentation of this type should be placed in the space provided. Additional information should be written on the reverse side of NAVMED 6600/13.

(k) Patient counseled today regarding the health hazards associated with tobacco use and where to seek cessation assistance: Patients who use tobacco must be counseled regarding the health hazards associated with tobacco use and where to seek cessation assistance. Place an "X" in the block when this information has been delivered. If the patient does not use tobacco, circle the "N/ A" entry.

(I) Patient has been advised of the findings of this examination and has verbalizedldemonstrated understanding. It is important that patients are fully apprised of the results of the dental exam and the recommended treatment. When this information has been delivered and in the examining doctor's opinion the patient has demonstrated an understanding, check the applicable box to affum/document.

(3) DATA ENTRY: Treatment needs are entered into the current reporting data base for departmentlclinic/commandlBUMED use. The numbers in this column are the sum total of numbers of teeth/quadrants/units to be treated rather than individual tooth/quadrantlunit identification numbers. Only one number is circled at a time in each department row. The column is updated after each patient visit by erasing the currently circled number and circling another appropriate number. For example, a patient had three Urgent lesions at the beginning of an operative appointment, and one lesion wa~ restored during the appointment. At the end of the appointment, in the Urgent Data Entry column of Operative, the circle around "3" would be erased and the "2" would be circled. When treatment is complete, no number is circled. For PSR Data Entry, circle the highest sextant score obtained (one entry only).

(4) SIGNATURE BOX: Places for signature, clinic, date and name stamp of dentist completing the examination.

(5) "DATE TREATMENT COMPLETED" BOX: When the treatment plan has been fully completed, this box will be completed with the date, provider's signature, name stamp, and clinic. In contrast with previous treatment plan completion, a new annual examination is not indicated. Per reference (c), annual dental examinations are to be performed coincident with the annual Preventive Health Assessment as part of the service member' s Individual Medical readiness requirement.

(6) DENTAL CLASSIFICATION (CLASS): Circle the appropriate number in pencil. When the class changes, erase the currently circled number and circle the new class number in pencil.

10 Enclosure (1)

3. Instructions for Completing the Back of NA VMED 6600/13


a. The back of NA VMED 6600113 is provided for recording narrative comments associated with the dental examination. NA YMED 6600/14 is used for related consultation, and to document treatment provided in the execution of the Treatment Plan.

b. For placement in the Dental Record, NAVMED 6600113 is placed with the Plan or "P" side facing up, on the backside of the middle page of the Dental Record Jacket opposite the NAYMED 6600/15. NAYMED 6600/135 will be in chronologicaJ order, with the most recent exam on top.

NA VMED 6600/145, EZ603s, SF603/603As, and other associated forms are located on the opposite page, in chronological order with most recent on top. NA VMED 6600115 always remains on top of these forms, opposite NA YMED 66oo/13s.

4. instructions for Completing the Forensics Section of the Dental Record Jacket

a. This section is printed directly on the inside of the back cover of the dentaJ record jacket.

b. It is intended that this section will be completed onJy once (usually at accession) during the member's service career and whenever substantial changes in the parameters used in forensic identification are made. If a replacement record is made, a new forensic examination must be completed.

c. All entries are made in black ink.

d. The teeth are separated on the odontogram to facilitate illustrating supernumerary teeth, mixed dentition, and interproximal restorations.

(1) If a restoration exists interproximaJly with no occlusaJ component, use the space to draw the restoration.

(2) When indicating fixed partiaJ dentures, ignore the spaces. Draw the prosthesis and indicate the materials and teeth involved in the remarks section.

e. Remarks: Use this section to indicate restorative materiaJs and differentiate between sealants, composites and temporaries.

f. Soft Tissue Remarks: PartiaJ list of the more common non-pathologic findings to facilitate charting. For each condition, indicate approximate size or extent and location. Leave blank if normal.

11 Enclosure ( I )

g. Occlusion:

(I) Angle's Class: I, II or III. Each side may be different.


(2) OveJjet and Overbite: Indicate in millimeters; leave blank if normal.

(3) Crossbite: Indicate teeth involved.

h. Hard Tissue Remarks: Partial Listing of the more common non-pathologic findings to facilitate charting. Leave blank if normal.

(I) Intrinsic Staining: Indicate teeth involved. Check tetracycline, if appropriate.

(2) Tori : Indicate location and approximate size.

(3) Rotated Teeth: Indicate teeth involved and approximate number of degrees to the nearest 45 degrees.

(4) Malposed Teeth: Indicate teeth involved and whether facio- or linguo- version.

I. Doctor's Name Stamp, Signature, Patient Identification Blocks: Complete as indicated.

5. Instructions for Completing the NAVMED 6600/15

a. NA VMED 6600/15 is the only authorized version of the Current Status form. All other versions in use are to be closed out at the first annual dental examination following release of this instruction using the following guidance:

(I) Indicate the date the existing form is closed.

(2) Place NA VMED 6600/15 over the top of the closed Current Status form and indicate the date placed in use. This date should be the same as the date used to close the previous form.

(3) Do not transcribe data from box 2 of the closed Current Status form onto the new form. Closed Forms will remain in the dental record as a diagrammatic record of treatment performed during the time the form was in use.

b. Box 1, Accession and Subsequent Diseases and Abnormalities:

(I) All carious lesions, indications for extraction, indications for root canal treatment, and periradicular lesions are drawn in pencil.

(2) When the indicated treatment is completed, the pencil entry is erased and completed treatment is diagramed in Box 2.

12 Enclosure (I)


c. Box 2, Missing Teeth at Time of Accession and Treatments Completed After Accession:

(1) This box is filled out in black ink. Otherwise, size, shape and location of markings are the same as indicated for Box I.

(2) All information, including extractions, restorations and root canal treatment, is cumulative for the dates indicated on the form.

(3) Missing teeth from the accession exam are also included in this box. All missing teeth are indicated by drawing a large "X" on the root or roots.

(4) When indicating fixed partial dentures, ignore the spaces and draw the prosthesis on each tooth as usual.

(5) Additional markings:

(a) Edentulous Mouth: Inscribe crossing lines. one extending from the maxillary right third molar to the mandibular left third molar and the other from the maxillary left third molar to the mandibular right third molar.

(b) Edentulous Arch: Make crossing lines each running from the uppermost aspect of one third molar to the lowermost aspect of the third molar on the opposite side.

(c) Temporary restorations: Outline the restoration showing size location and shape. Indicate the date placed and material used on the NAVMED 6600114.

(d) Partially erupted tooth: In the diagram of the tooth, draw an arcing line through the long axis.

(e) Impacted teeth: Outline all aspects of each impacted tooth with a single oval. The long axis of the tooth should be indicated by an arrow pointing in the direction of the crown.

(f) Drifted teeth: Draw an arrow at the designating number of the tooth that has moved, with the point of the arrow indicating the direction of movement.

(g) Implants replacing single rooted teeth: Draw wavy lines over the outline of the root structure and extend a few millimeters beyond the apex to represent the general shape of an implant screw. Block in.

(h) Implants replacing multi-rooted teeth: Draw wavy lines through the center of the root structure and extend a few millimeters beyond the apex to represent the general shape of an implant screw. Block in.

J3 Enclosure (I)

BUMEDINST 6600.l9 3 Sep 2010

d. Box 3, Medical Alert: The medical alert is placed on this form since it is readily viewable by aU clinicians when opening the record. If a medical alert exists, the word" ALERT" is written or stamped in large red letters with a brief explanation following.

e. Box 4, Patient Identification: Complete as indicated.

14 Enclosure (I)

BUMEDfNST 6600.19 3 Sep 2010

SAMPLE MARKINGS FOR USE ON NA VMED 6600/15, CURRENT STATUS

3 5 6 a 9 ' 0 1 t 12 13 14 " 16

31 20 19 " 17

T SRCP0NML K

Key

Note: Markings are the same for Box 1 (treatment planned) and Box 2 (treatment completed) unless otherwise noted.

Tooth I - tooth treatment planned for an extraction (Box I only) Tooth 2 - sealant Tooth 3 - planned implant for a multi-rooted tooth (Box I only) Tooth 4 - amalgam restoration Tooth 5 - combination restoration (mesio-occlusal (MO) amalgam restoration, mesio-buccle (MB) composite restoration) Teeth 6, 7, 9, 12, 13, 14, 19,23,29 and 31 - missing teeth (Box 2 only) Teeth 6, 7, 12 and 13 - removable appliances Tooth 8 - planned implant for a single rooted tooth (Box I only) Tooth 9 - implant completed on a single-rooted tooth (Box 2 only) Tooth 10 - root cana]/with radiolucent periradicular lesion Tooth II - porcelain fused to metal crown with post and root cana] Tooth 14 - implant completed on a multi-rooted tooth (Box 2 only) Tooth 15 - go]d restoration Tooth 16 - impacted and treatment planned for a distoangular extraction (Box I only) Tooth 17 - partially erupted tooth Teeth 18-20 - fixed partial denture (gold andlor other metaUic crowns and pontic) Tooth 21 - radiopaque periradicular lesion Tooth 22 - drifted tooth

Enclosure (2)

Tooth 24 - fractured tooth root Tooth 26 - apicoectomy with root canal and non-metallic restoration


Tooth 27 - non-metallic restoration (composite, porcelain, or glass ionomer) Teeth 28-30 - fixed partial denture (non-metallic crowns and pontic) Tooth 31 - example of multiple procedures (amalgam, root canal, gold crown, extraction and

implant) performed on the same tooth over an extended period of time (Box 2 only) Tooth 32 - mesioangular impacted tooth

2 Enclosure (2)

washington dc 20372·5300 in aepl v refer to bumedinst … · (b) na ymed 66001 is: in box i,...

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